title: Effect of the introduction of a financial incentive for fee-paying A&E attenders to consult their general practitioner before attending the A&E department.
abstract: BACKGROUND
  The Health (Out-Patient Charges) Regulations 1994 were designed to encourage those Irish patients liable for their own health care costs to attend their GP before their local Accident and Emergency (A&E) department. Such patients are referred to as General Medical Services (GMS)-ineligible. Prior to the introduction of the regulations in March 1994, there was a perverse financial incentive for these patients to attend directly A&E departments instead of their GP.
  
  
  OBJECTIVE
  The aim was to compare the number of GMS-ineligible patients referred by a GP during the year before and the year after the implementation of the Regulations.
  
  
  METHODS
  This study involved the audit of all new attendances to a large A&E department, for 1 year before and after the introduction of the new regulations. The main outcome measures were the number of new attenders in the subsequent year, the proportion of GMS-ineligible attenders, the proportion of GMS-ineligible attenders referred by a GP and the proportion of GMS-ineligible attenders referred by a GP and categorized as having neither critical nor urgent complaints.
  
  
  RESULTS
  The total number of new attenders in the year subsequent to the introduction of the regulations was 45,302, an increase of 4.9% on the previous year's total. The proportion of GMS-ineligible attenders decreased from 45.3 to 44% (-1.3%; 95% confidence interval (CI) -0.6 to -1.9). The proportion of GMS-ineligible attenders who were referred by a GP increased by 2.4% (95%; CI 1.7-3.1). The proportion of GMS-ineligible attenders, referred by a GP with complaints categorized as neither critical nor urgent, increased by 2.5% (95%; CI 1.8-3.2).
  
  
  CONCLUSIONS
  The introduction of the regulations was associated with a small, but statistically significant, reduction in the number of GMS-ineligible patients who attended with non-emergency conditions. The proportion of GMS-ineligible attenders who were referred by a GP increased by 2.4% (95%; CI 1.7-3.1). The overall workload of the A&E department was, however, unaffected. Further evaluation of the effects of this reduction on the health status of patients is required.
authors.affiliation: Department of General Practice, Royal College of Surgeons in Ireland, Mercer's Health Centre, Dublin, Ireland.
authors.forename: A W
authors.initials: AW
authors.lastname: Murphy
authors.forename: C
authors.initials: C
authors.lastname: Leonard
authors.forename: P K
authors.initials: PK
authors.lastname: Plunkett
authors.forename: G
authors.initials: G
authors.lastname: Bury
authors.forename: F
authors.initials: F
authors.lastname: Lynam
authors.forename: M
authors.initials: M
authors.lastname: Smith
authors.forename: D
authors.initials: D
authors.lastname: Gibney
mesh_terms: D000328:Adult; D016001:Confidence Intervals; D003363:Cost Control / Q000379:methods / Q000592:standards; D004636:Emergency Service, Hospital / Q000191:economics* / Q000706:statistics & numerical data*; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D017722:Hospital Charges; D006801:Humans; D007494:Ireland; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009042:Motivation; D011320:Primary Health Care / Q000191:economics / Q000706:statistics & numerical data; D015397:Program Evaluation; D012017:Referral and Consultation / Q000191:economics; D014218:Triage / Q000191:economics / Q000706:statistics & numerical data